Some perspective on medical errors
I’m not sure if this post will make you feel better or worse about the metal RI Hospital surgeons left in a woman’s scalp or the forceps they left in another patient’s abdomen. These mistakes are called “never events” by the medical community. They’re preventable and they should never happen.
But they do, more than you’d think. And they happen all over the country. Few states publicly report these mistakes, and those that do rarely report them as close to the actual event as Rhode Island does.
Here’s MA’s list of medical errors for 2009-
Massachusetts Acute Care Hospital SREs by Number and Percentage:
|January through December, 2009 Event||Count||Percent|
|Stage 3 or 4 Pressure Ulcer||65||17%|
|Retained Foreign Object||42||11%|
|Wrong Site Surgery||24||6%|
|Wrong Surgical Procedure||9||2%|
|Maternal Death / Disability||4||1%|
|Wrong Patient Surgery||0||0%|
|Hyperbilirubinemia in Neonate||0||0%|
|Death < 24 Hours ASA 1 Patient||0||0%|
|Contaminated Drugs or Device||0||0%|
|Infant Discharged to Wrong Person||0||0%|
|Artificial Insemination Error||0||0%|
|Oxygen or Gas Error||0||0%|
|Impersonation of Health Professional||0||0%|
I’ve put retained foreign object in bold- that’s the number of times surgeons leave forceps, metal, whatever inside a patient after surgery. This happened 42 times last year. Check out wrong site surgeries- another error that gets a lot of attention in RI- 24 times last year.
Yes, Rhode Island is much smaller than MA- they have about 6.5 million people. We have about a million. In that case, you’d think they’d have 6.5 times as many errors as RI, but it’s more. I have a call out to the Department of health to see our actual count of medical errors for 2009, but it terms of the reporting I’ve done, I can only remember two wrong site surgeries at RI hospital and one near miss at the Miriam.
But those are just two hospitals and MA has many more medical centers than we do. True. So, let’s check the data by hospital.
Here are all of the hospital that either had a wrong site surgery or a retained foreign object last year-
Hospital Name # Wrong site 2009 # Retained object 2009
BAYSTATE MEDICAL CENTER 2 2
BERKSHIRE MED CTR 0 1
BETH ISRAEL DEACONESS MED CTR 1 2
BEVERLY HOSP/BEVERLY CAMPUS 3 0
BRIGHAM & WOMEN’S HOSPITAL 2 3
CAMBRIDGE HLTH ALLIANCE 1 0
CAPE COD HOSPITAL 1 0
CARITAS HOLY FAMILY HOSPL 0 2
FAIRVIEW HOSPITAL 0 1
FALMOUTH HOSPITAL 0 1
FAULKNER HOSPITAL CORP. 0 1
HARRINGTON MEMORIAL HOSPITAL 0 1
JORDAN HOSPITAL 1 2
LOWELL GENERAL HOSPITAL 0 1
MASS EYE & EAR INFIRMARY 1 0
MASS GENERAL HOSPITAL 3 6
And the list goes on….
When’s the last time Mass General apologized for a wrong site surgery? The hospital had 3 last year as well as 6 objects left inside a patient.
Again, these events should never happen, but there’s something wrong with our hospital systems in general, not just Rhode Island’s hospitals.